Order Form: Fixed Fee Collection Service

Company Information:

Company Name: (required)

Attn: (optional)

Address: (required)

City: (required)

State: (required)
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto Rico

Zip: (required)

Phone (required)

What is your Industry (required)
---MedicalDentalEducationEnergyFinanceAutomotiveGovernmentConstructionLegalTechnologyUtilityOther

Primary Contact:

Your Name: (required)

Your Email: (required)

What AR Software do you use?
NoneAtnenaHealthDentrixEaglesoftPulseQuickBooksRaintreeOther

Collection Calls Service Fees:

(Contingency Collections: No payment required. No Recovery-No Fees)
Kinum's Commission Fees:
40% : Any Amount / Age
50% : Legal
50% : Mail Returns

Service Options

Transfer Preference:
All accounts which remain unpaid after Collection Demands (Step 2) service can be automatically transferred to the next step, Collection Calls Service (Step 3), after waiting for 15 days. We recommend "Yes", but its your choice.
NO - I will manually select and transfer accountsYES - Transfer all accounts automatically after 15 days

Credit Reporting:
If you select "Yes", you authorize Kinum to report Step 3 debts to the credit bureaus on your behalf. You agree to abide by all rules set forth by the Fair Credit Reporting Act (FCRA).
NO - Do not report to Credit BureausYES - Please report to Credit Bureaus

Terms and Service Agreement

I have read and accepted the Privacy Policy & Terms of use

I have read the Service Agreement and e-Signing it by checking the box